Citation Nr: 18131306
Decision Date: 08/31/18	Archive Date: 08/31/18

DOCKET NO. 10-24 953
DATE:	August 31, 2018
ORDER
Entitlement to service connection for hypertension is denied.
Entitlement to service connection for a left elbow disorder is denied.
Entitlement to service connection for a right elbow disorder is denied.
Entitlement to service for trans ischemic attack (TIA)/stroke residuals is denied. 
New and material evidence having been received the petition to reopen the claim of service connection for a left knee disorder, to include degenerative joint disease, is granted.
New and material evidence having been received, the petition to reopen the claim of service connection for a right knee disorder, to include degenerative joint disease, is granted.
REMANDED
Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is remanded.
Entitlement to service connection for a blood disorder, to include essential thrombocythemia and myelodysplastic syndrome, is remanded.
Entitlement to service connection for diabetes mellitus (DM) is remanded.
Entitlement to service connection for a left knee disorder is remanded.
Entitlement to service connection for a right knee disorder is remanded.  
Entitlement to service connection for dementia is remanded.
Entitlement to an increased evaluation for cervical spine degenerative disc disease is remanded.
FINDINGS OF FACT
1. Hypertension was not manifest in service, within one year of separation from service, and is not otherwise related to the Veteran's active service. 
2. A right elbow disorder, to include arthritis, was not manifest in service, within one year of separation from service, and is not otherwise related to the Veteran's active service.
3. A left elbow disorder, to include arthritis, was not manifest in service, within one year of separation from service, and is not otherwise related to the Veteran's active service.
4. A TIA/stroke was not manifest in service, within one year of separation from service, and is not otherwise related to the Veteran's active service.
5. The RO denied entitlement to service connection for a left knee disorder in December 2009.  The Veteran was notified of this decision that same month and did not file a notice of disagreement nor was evidence received within the proscribed periods which would have allowed the claim to remain open. 
6. The RO denied entitlement to service connection for a right knee disorder in December 2009.  The Veteran was notified of this decision that same month and did not file a notice of disagreement nor was evidence received within the proscribed period which would have allowed the claim to remain open
7. Evidence received since the denial of entitlement to service connection for a left knee disorder raises a reasonable possibility of substantiating the claim.
8. Evidence received since the denial of entitlement to service connection for a right knee disorder raises a reasonable possibility of substantiating the claim. 
CONCLUSIONS OF LAW
1. The criteria for service connection for hypertension have not been met.  38 U.S.C. §§ 1101, 1110, 1112, 1117, 1131, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017).
2. The criteria for service connection for a left elbow disorder, to include arthritis, have not been met.  38 U.S.C. §§ 1101, 1110, 1112, 1117, 1131, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017).
3.  The criteria for service connection for a right elbow disorder, to include arthritis, have not been met.  38 U.S.C. §§ 1101, 1110, 1112, 1117, 1131, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017).
4. The criteria for service connection for a TIA/stroke residuals have not been met.  38 U.S.C. §§ 1101, 1110, 1112, 1117, 1131, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017).
5. The December 2009 rating determination denying service connection for a left knee disorder became final.  38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 20.302, 20.1103 (2017).
6. New and material evidence sufficient to reopen the claim of service connection for a left knee disorder has been received.  38 U.S.C. § 5108, 7105 (2012); 38 C.F.R. § 3.156 (2017). 
7. The December 2009 rating determination denying service connection for a right knee disorder became final.  38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 20.302, 20.1103 (2017).
8. New and material evidence sufficient to reopen the claim of service connection for a right knee disorder has been received.  38 U.S.C. § 5108, 7105 (2012); 38 C.F.R. § 3.156 (2017). 
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran, who is the appellant, had active service from June 1974 to June 1994.
These matters come before the Board of Veterans’ Appeals (Board) on appeal from various rating determination of the Regional Office (RO).  
As to the issues of service connection for hypertension and a blood disorder, to include essential thrombocythemia and myelodysplastic syndrome, these issues were before the Board in August 2016, at which time the Board denied service connection for a blood disorder, to include essential thrombocythemia and myelodysplastic syndrome, and remanded the issue of hypertension for further development.  
The Veteran subsequently appealed the issue of service connection for a blood disorder, to include essential thrombocythemia and myelodysplastic syndrome, to the United States Court of Appeals for Veterans Claims (Court).  In conjunction with the appeal, a Joint Motion for Partial Remand (JMPR) was filed in March 2017 requesting that the denial be vacated and that the matter remanded for actions consistent with the JMPR.  Later that month, the Court granted the JMPR and remanded the matter for actions consistent with the JMPR.  
The RO initially addressed the issues of service connection for left and right knee disorders on the basis of whether new and material evidence had been received. The RO subsequently reopened the claims and addressed the issues on a de novo basis.  Regardless of the RO's actions, the Board is required to determine if there was new and material evidence received.  Jackson v. Principi, 265 F. 3d 1366 (Fed. Cir. 2001). Accordingly, the Board will address the issues of whether new and material evidence has been received to reopen the claims of service connection for left and right knee disorders.
Service Connection
Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).  Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).  As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service.  Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). 
The existence of a current disability is the cornerstone of a claim for VA disability compensation.  See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).
As it relates to a qualifying chronic disability, service connection may be established on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis.  38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1) (VA has issued an interim final rule extending this date to December 31, 2021).  In claims based on undiagnosed illness, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service.  Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004).  Notably, laypersons are competent to report objective signs of illness.  Id.  A "qualifying chronic disability" for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (C), any diagnosed illness that the VA Secretary determines in regulation prescribed under 38 U.S.C.§ 1117(d) warrants a presumption of service connection.  38 U.S.C. § 1117 (a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B).
"Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification.  To fulfill the requirement of chronicity, the illness must have persisted for a period of six months.  38 C.F.R. § 3.317(a)(2),(3).  Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders.  38 C.F.R. § 3.317(b).
Effective July 13, 2010, VA has amended its adjudication regulations governing presumptions for certain Persian Gulf War Veterans.  Such revisions amend § 3.317(a)(2)(i)(B) to clarify that chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome are examples of medically unexplained chronic multisymptom illnesses and are not an exclusive list of such illnesses.  Additionally, the amendment removes § 3.317(a)(2)(i)(B)(4) which reserves to the VA Secretary the authority to determine whether additional illnesses are 'medically unexplained chronic multisymptom illnesses' as defined in paragraph (a)(2)(ii) so that VA adjudicators will have the authority to determine on a case-by-case basis whether additional diseases meet the criteria of paragraph (a)(2)(ii).  These amendments are applicable to claims pending before VA on October 7, 2010, as well as claims filed with or remanded to VA after that date.  See 75 Fed. Reg. 1,997 (Oct. 7, 2010).
Compensation under 38 U.S.C. § 1117 shall not be paid if: (1) there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs.  38 C.F.R. § 3.317(c).
The term "Persian Gulf Veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War.  38 C.F.R. § 3.317 (d)(1).  The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations.  See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(d)(2).  The Persian Gulf War period runs from August 2, 1990 to a date not later than December 31, 2021. 38 U.S.C.§ 101(33).
It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case.  When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant.  38 C.F.R. § 3.102. 
In evaluating the evidence in any given appeal, the Board has been charged with the duty to assess the credibility and weight given to evidence.  Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006); Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991).  Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so.  Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992).
Hypertension, arthritis, and stroke are "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provision of 38 C.F.R. § 3.303(b) apply to those claims.  Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).  If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection.  38 C.F.R. § 3.303(b).  Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).
Hypertension, arthritis, and stroke will be presumed to have been incurred in service if manifested to a compensable degree within the first year following separation from active duty.  38 U.S.C.§§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309.
1. Hypertension
The Veteran contends that he currently has hypertension as a result of his military service in the Persian Gulf.  He alleges that he suffered a stroke in service as a result of hypertension.  Alternatively, he contends that he was exposed to oil and smoke while in the Persian Gulf, which could have resulted in his current condition.
Service treatment records do not reveal any findings of hypertension in service.  At the time of the Veteran’s March 1991 redeployment examination, a blood pressure reading of 120/80 was recorded.  Cardiopulmonary testing performed in April 1994 revealed a blood pressure reading of 120/80.  At the time of the Veteran’s May 1994 service separation examination, a blood pressure reading of 112/78 was recorded.  Bruce Protocol testing performed in August 1995 revealed a blood pressure reading of 190/85.  A blood pressure reading in September 2001 was 140/70, with it being noted at that time that the Veteran had had a stroke two months earlier.  The Veteran was diagnosed as having essential hypertension in February 2008.  
In conjunction with his claim, the Veteran was afforded a VA examination in July 2015.  At that time, a diagnosis of hypertension was rendered with an onset date of 2008.  Following examination of the Veteran and review of the record, the examiner opined that the Veteran’s hypertension was less likely than not due to service, to include his reports of a stroke and high blood readings or exposure to smoke or oil while in service in the Persian Gulf.  The examiner further indicated that hypertension was not manifested within one year of service separation in June 1994.  She indicated that the transient blood pressure reading noted during Bruce Protocol testing in August 1995, as part of a cardiac evaluation, was an expected outcome, and normalized after the procedure.  She noted that hypertension was diagnosed in 2008, a gap of 14 years after the military.  The examiner observed that there were multiple risk factors causing hypertension such as genetics, excess sodium intake, alcohol intake, obesity, weight gain, physical inactivity, dyslipidemia, certain personality traits, and Vitamin D deficiency.  
In its August 2016 remand, the Board found that the July 2015 VA examiner’s opinion was inadequate as she failed to provide a rationale for her opinion that the Veteran's hypertension was not otherwise related to service.  In this regard, she referenced certain risk factors that could cause hypertension, but failed to discuss whether the Veteran had any of the risk factors, let alone whether they caused his hypertension.  Thus, as the examiner failed to provide a rationale for her opinion that the Veteran's hypertension was not related to his service, the Board found that an additional opinion was necessary.
The requested VA opinion was obtained in August 2016.  Following a review of the record, the examiner indicated that the Veteran’s diagnosis of hypertension was less likely than not caused by, related to, or worsened beyond natural progression by military service or by exposure to smoke and oil in service.  The examiner indicated that as per accepted guidelines, the diagnosis of hypertension was not based on isolated elevations of blood pressure, but consistent, persistent, documented elevations, performed in the proper clinical setting.  This was done to exclude blood pressure readings which may be unusable for diagnosis, such as when taken in a nonstandard clinical setting, or when the patient has external stressors such as pain, medications, or environmental situations which may transiently raise blood pressure in an otherwise normotensive patient.  He further observed, that additionally, variable elevations of blood pressure in non-hypertensive patients may be noted when the patient is responding to the stress of being in a clinical environment (white coat syndrome).  The examiner indicated that the Veteran clearly did not have a diagnosis of hypertension in service, nor did he appear to have such a diagnosis for some years afterwards.  The examiner noted that the diagnosis of hypertension was based on multiple visits in a clinical setting, and the Veteran’s memory of isolated elevations of BP was not consistent with the clinical requirements for making such a diagnosis.  Additionally, chronologic medical record documentation of symptoms and illness was the most accurate indicator of the past.  Research had "repeatedly shown that memory is spectacularly unreliable and malleable.  We routinely add or subtract people, details, settings and actions to and from our memories.  We conflate, invent and edit."(Scientific American, Psychology, April 2009 pg 66.).  He further opined that hypertension itself was considered an asymptomatic disease.  Further, exposure to smoke and oil, while possibly causing a stressful situation with transient elevations of blood pressure appropriate to the situation, had not been shown to contribute to or cause the long term, unremitting, sustained elevation of blood pressure which was required for the diagnosis of hypertension.
As discussed above, the weight of the evidence demonstrates that the Veteran has been diagnosed with hypertension.  Because this condition has a specific diagnosis, it is not an undiagnosed illness and service connection under 38 C.F.R. § 3.317 is not warranted.
The Board next finds that the weight of the evidence shows that no vascular injury or disease occurred during a period of active service, and no chronic symptoms of hypertension were manifested during active service.  The active duty service treatment records show no complaint of, diagnosis of, or treatment for a vascular injury or high blood pressure.  There was no evidence of high blood pressure/hypertension until 2008.  While the Board notes that the Veteran was shown to have an elevated blood pressure reading during Bruce Protocol testing in August 1995, this was to be expected and normalized after the testing.  Because service treatment records, which are complete, show no vascular injury, vascular disease, or symptoms of hypertension during active service, and such conditions would have ordinarily been recorded during service because the vascular system was evaluated during service, the weight of the evidence demonstrates that there were no "chronic" symptoms of hypertension during service. 
The Board next finds that the weight of the evidence is against a finding that symptoms of hypertension were continuously manifested since active service, including to a degree of ten percent disabling within one year of service separation.  See 38 C.F.R. § 4.104, Diagnostic Code 7101.  The earliest evidence of a hypertension diagnosis reflected in the evidence of record is shown in 2008, approximately 14 years after service separation.  The absence of post-service findings of, diagnosis of, or treatment for hypertension for over 14 years after service separation is one factor that tends to weigh against a finding of hypertension in service or continuous symptoms after service separation, including to a compensable degree within the first post-service year.  See Buchanan v. Nicholson, 451 F.3d 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor to consider as evidence against a claim of service connection). 
The Veteran has asserted that he has experienced hypertension since his period of active service.  Such recent assertions, however, are inconsistent with, and outweighed by, other lay and medical evidence of record, including the Veteran's service treatment records and no reports of high blood pressure in the years immediately following service.  See Gardin v. Shinseki, 613 F.3d 1374, 1380 (Fed. Cir. 2010) (upholding Board finding that vague and inconsistent lay statements were not credible because they were in direct contradiction to the more credible, competent, reliable, and clearly documented medical evidence); Madden v. Gober, 125 F.3d 1477, 1481 (Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service).
Insomuch as the Veteran has attempted to establish a continuity of symptomatology or nexus through his own lay assertions, the Board finds that the etiology of hypertension falls outside the realm of common knowledge of a layperson and the Veteran is, thus, not competent to provide evidence on the issue of causation.  See Jandreau, 492 F.3d 1372, 1377 n.4.  Opinions as to causation involve making findings based on medical knowledge and clinical testing results, and the cardiovascular system is complex and involves unseen systems processes and disease processes that are not observable by the five senses of a lay person. Although the Veteran is competent to report having had high blood pressure readings at any given time, he has not been shown competent to identify latent symptoms of hypertension, or relate symptoms, patent or latent, to a diagnosis of hypertension.  The evidence does not show clinical documentation of hypertension until many years after service.  Consequently, the Veteran's opinion that purports to establish continuity of symptomatology or relate hypertension to active service is of no probative value. 
Next, service connection may be granted when the evidence establishes a medical nexus between a claimed disability and service.  When evaluating the weight of medical evidence, the Board is guided by the principle that the probative value of a medical opinion largely rests upon the extent to which such opinion is based upon a thorough evaluation of the Veteran's medical history, including but not limited to the medical evidence contained in the claims file.  See, e.g. Miller v. West, 11 Vet. App. 345, 348.  The Board may examine the factual foundation of a medical opinion, including whether the physician had access to relevant information of record.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). 
The Board notes that the Veteran has not submitted competent or probative medical evidence specifically indicating that his current hypertension is related to his period of service, to include as a result of his Gulf War service.  The Veteran's elevated blood pressure readings have been assessed as a diagnosed condition not an unexplained undiagnosed illness.  In conjunction with the Board remands, several VA opinions were obtained, including the August 2016 opinion, wherein the examiner stated that a diagnosis of hypertension was less likely than not caused by, related to, or worsened beyond natural progression by military service or by exposure to smoke and oil.  As noted above, the examiner provided detailed rationale for the opinion.  
The Veteran's entire record, which at the time included his service treatment records, private and VA treatment records, and statements from the Veteran, was reviewed.  Based on all the evidence, the examiner rendered an opinion that was supported by a detailed and complete rationale.  There was no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact.  Thus, the Board finds this opinion to be the most probative evidence of record.
Because the record does not show vascular injury, vascular disease, or chronic symptoms of hypertension during active service, continuous symptoms of hypertension since active service, hypertension manifested to a compensable degree within one year of active service separation, or hypertension otherwise related to active service, service connection for hypertension may not be established.  38 C.F.R. §§ 3.303, 3.307, 3.309.
Right and Left Elbow Disorders
The Veteran contends that his current left and right elbow disorders, to include degenerative joint disease, had their onset in service arising out of duties performed while in service.  The Veteran’s service treatment records do not reveal any findings or diagnoses of any left elbow disorder.  The Veteran was seen with complaints of right elbow pain.  Treatment records note a diagnosis of elbow strain in July 1992 after lifting furniture, at which time the Veteran was prescribed Motrin.  At the time of the Veteran’s May 1994 service separation examination, there were no complaints or findings of elbow problems, with normal findings being reported for the upper extremities.  On his April 1994 report of medical history, the Veteran did not report having elbow problems and checked the “no” box when asked if he had a trick elbow.  There were no complaints or findings of elbow problems in the years immediately following service.  The Veteran was not diagnosed with degenerative joint disease of either elbow for many years following service.  
In conjunction with his claim the Veteran was afforded a VA examination in September 2010.  Following review of the record and examination of the Veteran, a diagnosis of bilateral elbow degenerative joint disease was rendered.  The examiner indicated that the Veteran had a claimed disability pattern related to elbow pain that met TL1001 criteria for a disease with a clear and specific etiology and diagnosis and was less likely than not caused by or related to GW environmental exposure, more likely than not age-related.
In a January 2011 addendum report, the VA examiner again rendered a diagnosis of bilateral elbow arthritis.  She stated the claimed condition was less likely than not related to inservice complaints (right elbow pain, right elbow strain and right elbow furuncle) shown during service, more likely age related.  She noted that the Veteran had a claimed disability pattern related to elbow pain that met the criteria for a disease with a clear and specific etiology and diagnosis.  She again indicated that it was less likely than not caused by or related to GW environmental exposure, more likely than not age-related.  
As discussed above, the weight of the evidence demonstrates that the Veteran has been diagnosed with right and left elbow arthritis.  Because these conditions have specific diagnoses, they are not undiagnosed illnesses and service connection under 38 C.F.R. § 3.317 is not warranted.
The Board next finds that the weight of the evidence is against a finding that symptoms of left or right elbow problems were continuously manifested since active service, including to a degree of ten percent disabling within one year of service separation.  The Veteran was not treated for a left elbow disorder in service or in the years immediately following service.  Although the Veteran was treated for a right elbow problem in service, this resolved, as evidenced by no reports or complaints of right elbow problems at the time of separation and normal findings for the upper extremities at the time of the May 1994 service separation examination.  The earliest evidence of right or left elbow degenerative joint disease was many years following service.  The absence of post-service findings of, diagnosis of, or treatment for right or left elbow problems many years after service separation is one factor that tends to weigh against a finding of left or right elbow problems in service or continuous symptoms after service separation, including to a compensable degree within the first post-service year.  See Buchanan v. Nicholson, 451 F.3d 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor to consider as evidence against a claim of service connection). 
The Veteran has asserted that he has had elbow problems since service.  Such recent assertions, however, are inconsistent with, and outweighed by, other lay and medical evidence of record, including the Veteran's service treatment records and the Veteran not reporting any complaints of elbow problems on his April 1994 report of medical history or at the time of his May 1994 retirement examination.  The Veteran also did not report having elbow problems on his initial application for compensation benefits.  See Gardin v. Shinseki, 613 F.3d 1374, 1380 (Fed. Cir. 2010) (upholding Board finding that vague and inconsistent lay statements were not credible because they were in direct contradiction to the more credible, competent, reliable, and clearly documented medical evidence); Madden v. Gober, 125 F.3d 1477, 1481 (Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service).
Insomuch as the Veteran has attempted to establish a continuity of symptomatology or nexus through his own lay assertions, the Board finds that the etiology of arthritis of the elbow falls outside the realm of common knowledge of a layperson and the Veteran is, thus, not competent to provide evidence on the issue of causation.  See Jandreau, 492 F.3d 1372, 1377 n.4.  The evidence does not show clinical documentation of arthritis until many years after service.  Consequently, the Veteran's opinion that purports to establish continuity of symptomatology or relate his current left or right elbow arthritis to active service is of no probative value. 
Next, service connection may be granted when the evidence establishes a medical nexus between a claimed disability and service.  The Board notes that the Veteran has not submitted competent or probative medical evidence specifically indicating that his current left or right elbow arthritis is related to his period of service.  The Veteran's left and right elbow problems have been assessed as a diagnosed condition not an unexplained undiagnosed illness.  Several opinions have been obtained with regard to the left and right elbow disorders, wherein the examiner has indicated that the Veteran’s right and left elbow disorders are not as least as likely as not related to his period of service.  As noted above, the examiner provided detailed rationale for the opinion.  
The Veteran's entire record, which at the time included his service treatment records, private and VA treatment records, and statements from the Veteran, was reviewed.  Based on all the evidence, the examiner rendered an opinion that was supported by a detailed and complete rationale.  There was no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact.  Thus, the Board finds this opinion to be the most probative evidence of record.
Because the record does not show a right or left elbow injury, arthritis, or chronic symptoms of right or left elbow problems during active service, continuous symptoms of right or left elbow problems since active service, arthritis manifested to a compensable degree within one year of active service separation, or right or left elbow arthritis otherwise related to active service, service connection for a left or right elbow disorder, to include arthritis, may not be established.  38 C.F.R. §§ 3.303, 3.307, 3.309.
TIA/Stroke Residuals
The Veteran contends that his TIA/stroke residuals had their onset in service.  The Veteran’s service treatment records do not reveal any findings or diagnoses of any TIAs or stroke.  At the time of the Veteran’s May 1994 service separation examination, there were no complaints or findings relating to TIA/stroke symptoms.  On his April 1994 report of medical history, the Veteran did not report having any TIA or stroke symptoms.  There were no complaints or findings of TIA/stroke problems in the years immediately following service.  The Veteran was not diagnosed with TIA/stroke problems until at least 2001.  
In conjunction with his claim the Veteran was afforded a VA examination in September 2010.  At that time, the examiner noted that in 2002, the Veteran was admitted to the Madigan Medical Center with a diagnosis TIA (Mini stroke) manifested by drooping of lips, slurring of speech, and weakness of left side of the body, which resolved in 24hrs.  He was placed under observation for several weeks and discharged improved.  The examiner rendered a diagnosis of TIA (claimed stroke) resolved.  The examiner indicated that the Veteran had a claimed disability pattern related to slurring of speech and weakness of left side drooping of lips that met TL1001 criteria for a disease with a clear and specific etiology and diagnosis, less likely than not caused by or related to GW environmental exposure, more likely due to risk factors such as hypertension and smoking history.
As discussed above, the weight of the evidence demonstrates that the Veteran has been diagnosed with TIA/stroke residuals, resolved.  Because these conditions have specific diagnoses, they are not undiagnosed illnesses and service connection under 38 C.F.R. § 3.317 is not warranted.
The Board next finds that the weight of the evidence is against a finding that symptoms of TIA/stroke were continuously manifested since active service, including to a degree of ten percent disabling within one year of service separation.  The Veteran was not treated for a TIA/stroke in service or in the years immediately following service.  The earliest evidence of TIA/stroke was many years following service.  The absence of post-service findings of, diagnosis of, or treatment for TIA/stroke problems many years after service separation is one factor that tends to weigh against a finding of TIA/stroke problems in service or continuous symptoms after service separation, including to a compensable degree within the first post-service year.  
The Veteran has asserted that he has experienced TIA/stroke problems since service.  Such recent assertions, however, are inconsistent with, and outweighed by, other lay and medical evidence of record, including the Veteran's service treatment records showing no TIA/stroke complaints and the Veteran not reporting any complaints of TIA/stroke problems on his April 1994 report of medical history or at the time of his May 1994 retirement examination.  The Veteran also did not report having TIA/stroke problems on his initial application for compensation benefits.  
Insomuch as the Veteran has attempted to establish a continuity of symptomatology or nexus through his own lay assertions, the Board finds that the etiology of TIA/stroke falls outside the realm of common knowledge of a layperson and the Veteran is, thus, not competent to provide evidence on the issue of causation.  See Jandreau, 492 F.3d 1372, 1377 n.4.  The evidence does not show clinical documentation of TIA/stroke until many years after service.  Consequently, the Veteran's opinion that purports to establish continuity of symptomatology or relate any current TIA/stroke residuals to active service is of no probative value. 
Next, service connection may be granted when the evidence establishes a medical nexus between a claimed disability and service.  The Board notes that the Veteran has not submitted competent or probative medical evidence specifically indicating that he currently has any TIA/stroke residuals related to his period of service.  The Veteran's TIA/stroke is a diagnosed condition not an unexplained undiagnosed illness.  
An opinion has been obtained wherein the examiner has indicated that the TIA/stroke residuals were not as least as likely as not related to his period of service.  As noted above, the examiner provided detailed rationale for the opinion.  The Veteran's entire record, which at the time included his service treatment records, private and VA treatment records, and statements from the Veteran, was reviewed.  Based on all the evidence, the examiner rendered an opinion that was supported by detailed and complete rationale.  There was no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact.  Thus, the Board finds this opinion to be the most probative evidence of record.
Because the record does not show a TIA/stroke or chronic symptoms of TIA/stroke during active service, continuous symptoms of TIA/stroke problems since active service, TIA/stroke manifested to a compensable degree within one year of active service separation, or TIA/stroke otherwise related to active service, service connection for TIA/stroke may not be established.  38 C.F.R. §§ 3 .303, 3.307, 3.309.
New and Material Evidence 
Prior unappealed rating decisions may not be reopened absent the submission of new and material evidence warranting revision of the previous decision.  38 U.S.C.  5108; 38 C.F.R. § 3.156.  "New" evidence means evidence "not previously submitted to agency decisionmakers."  38 C.F.R. § 3.156(a).  "Material" evidence means "evidence that, by itself or when considered with previous evidence of record, related to an unestablished fact necessary to substantiate the claim."  Id.  
The Court has elaborated that material evidence is: (1) evidence on an element where the claimant initially failed to submit any competent evidence; (2) evidence on an element where the previously submitted evidence was found to be insufficient; (3) evidence on an element where the appellant did not have to submit evidence until a decision of the Secretary determined that an evidentiary presumption had been rebutted; or (4) some combination or variation of the above three situations.  Kent v. Nicholson, 20 Vet. App. 1 (2006).
In order to be "new and material" evidence, the evidence must not be cumulative or redundant, and "must raise a reasonable possibility of substantiating the claim," which has been found to be enabling, not preclusive.  See Shade v. Shinseki, 24 Vet. App. 110 (2010).  When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed.  Justus v. Principi, 3 Vet. App. 510, 513 (1991).
Further, RO decisions become final "only after the period for appeal has run," and "[a]ny interim submissions before finality must be considered by the VA as part of the original claim."  Jennings v. Mansfield, 509 F.3d 1362, 1368 (Fed. Cir. 2007).  If new and material evidence is received within one year after the date of mailing of an RO decision, it may be "considered as having been filed in connection with the claim which was pending at the beginning of the appeal period that prevents an initial determination from becoming final."  King v. Shinseki, 23 Vet. App. 464, 466-67 (2010). 
When VA fails to consider new and material evidence submitted within the one-year appeal period pursuant to § 3.156(b), and that evidence establishes entitlement to the benefit sought, the underlying RO decision does not become final.  Young v. Shinseki, 22 Vet. App. 461, 466 (2009); see also Buie v. Shinseki, 24 Vet. App. 242, 252 (2011) (remanding for the Board to consider the application of 38 C.F.R. § 3.156(b) and whether the regional office correctly viewed the statements in question "as new claims").  In Buie, the Court explained that, when statements are received within one year of the rating decision, the Board's inquiry is not limited to whether those statements constitute notices of disagreement but whether those statements include the submission of new and material evidence under 38 C.F.R. § 3.156(b).  Id.
Left Knee Disorder, to Include Degenerative Joint Disease
In a December 2009 rating determination, the RO noted that service connection for a left knee condition was previously denied in the rating decision of February 2006, which found that there was no evidence of any permanent residual or chronic left knee condition incurred in service or manifest to a compensable degree within one year of separation from service.  It noted that the Veteran was notified of the decision in March 2006, and the decision was final one year from that date.  The RO indicated that the Veteran could reopen a finally adjudicated claim by submitting new and material evidence.  The RO observed that since the previous denial of service connection for left knee injury, VA policies and procedures had changed with regard to claims for service connection and it was noted that a VA examination for a medical opinion was required if the evidence showed an event in service and current medical or lay evidence of a condition possibly related to the event in service.  
The RO observed that the Veteran was treated for left knee pain and pain in the thigh near the groin in service in 1974 and that medical evidence showed he had a current left knee condition.  The claim was successfully reopened for the purpose of obtaining a medical opinion regarding whether the current left knee condition was related to military service.  The RO observed that the medical evidence reviewed in connection with the claim showed ongoing treatment for left knee pain.  The RO noted that a VA examination was performed in December 2009, at which time it was noted that the Veteran was treated in service in 1974 for left knee and upper thigh pain that was assessed as myositis.  The pain was shown to be resolved on follow-up five days later.  There was no further record of left knee problems in service and no report or findings of any knee problems on the separation examination in 1994.  The RO noted that the Veteran reported that his left knee pain began in the 1990s and that he had constant pain and some stiffness.  Following examination, a diagnosis of left knee arthritis was rendered.  The examiner expressed that this condition was not related to the left knee pain treated in service as the evidence of record clearly showed that the Veteran had no sequelae from that injury as indicated on the separation examination in 1994, which did not include any report or findings of any knee problems.
The RO indicated the previous denial of service connection for left knee condition was confirmed and continued as the evidence of record failed to show any permanent residual or chronic left knee condition was incurred in or aggravated by military service or manifest to a compensable degree within one year of separation from service or that the current left knee condition was related to the acute and transitory left knee condition treated in service in 1974.  
The Veteran was notified of the decision later that month and did not appeal, nor was evidence received which would have allowed the claim to remain open.  Thus, the decision became final.  
Evidence available at that time included statements from the Veteran. VA and private treatment records, and the results of the December 2009 VA examination.
Evidence received subsequent to the December 2009 rating decision, includes numerous VA and private treatment records, several reports and opinions from the Veteran’s treating physicians, and the results of a VA examination performed in connection with the Veteran’s claim.  
In support of his claim, the Veteran has submitted several letters showing his treating physicians’ beliefs that his current knee disorders are related to his period of service.  In a March 2010 statement, the Veteran’s physician, J. S., M.D., specifically indicated that the Veteran knee problems were a direct result of his service.  He noted that the Veteran’s knee disorders could be traced back to injuries or working conditions that he was exposed to while on active duty.  
In an April 2016 letter, the Veteran’s private physician, V. B., M.D., indicated that the Veteran had been a patient of his since 2011.  He noted that it was his belief that the Veteran’s osteoarthritis and chondromalacia of the patella were service-related.  
The newly received evidence relates to previously unestablished elements of the claim of a current disability and a possible link between the current disability and service, and provides a reasonable possibility of substantiating the claim.  38 C.F.R. § 3.156(a).
For these reasons, the Board finds that the evidence received since the December 2009 rating determination is new and material to reopen service connection for a left knee disorder.  38 U.S.C. § 5108; 38 C.F.R. § 3.156.  The reopened issue will be addressed in the remand section below.
Right Knee Disorder, to Include Degenerative Joint Disease  
In a December 2009 rating determination, the RO noted that service connection for a right knee injury was previously denied in a March 1995 rating determination, which found that there was no evidence of any permanent residual or chronic right knee condition incurred in service or found on a VA examination shortly after separation from service.  The Veteran was notified of the decision later that month, and the decision was final one year from that date.  The RO noted the policies and procedures had changed with regard to claims for service connection and that a VA examination for a medical opinion was required if the evidence showed an event in service and current medical or lay evidence of a condition possibly related to the event in service.  
The RO observed that the Veteran was treated for right knee pain in service in 1993 and that medical evidence showed he had a current right knee condition.  The RO reopened the claim for the purpose of obtaining a medical opinion.  The RO indicated that the medical evidence reviewed in connection with the claim showed ongoing treatment for right knee pain.  It observed that he Veteran had surgery to repair a torn meniscus in June 2009, but had continuing pain after the surgery and a one-month course of physical therapy.  There was more physical therapy at VA from October 2 to November 23, 2009.
The RO noted that at the time of the December 2009 VA examination, an X-ray of the knee was normal.  Following examination, a diagnosis of right knee status post medial meniscal tear with arthroscopic repair was rendered.  The examiner opined that this condition was not related to the right knee contusion treated in service as the evidence of record clearly showed that the Veteran had no sequelae from that injury as indicated on the separation examination in 1994, which did not include any report or findings of knee problems.  
The RO indicated that the previous denial of service connection for right knee injury was confirmed and continued as the evidence of record failed to show any permanent residual or chronic right knee condition was incurred in or aggravated by military service or manifest to a compensable degree within one year of separation from service or that the current right knee condition was related to the acute and transitory injury to the right knee in service in 1993.
Evidence available at that time included statements from the Veteran, VA and private treatment records, and the results of the December 2009 VA examination.
Evidence received subsequent to the December 2009 rating decision includes numerous VA and private treatment records, several reports and opinions from the Veteran’s treating physicians, and the results of a VA examination performed in connection with the Veteran’s claim.  
In support of his claim, the Veteran has submitted several letters showing his treating physicians’ beliefs that his current knee disorder is related to his period of service.  In a March 2010 statement, the Veteran’s physician, J. S., M.D., specifically indicated that the Veteran knee problems were a direct result of his service.  He noted that the Veteran’s knee disorders could be traced back to injuries or working conditions that he was exposed to while on active duty.  
In an April 2016 letter, the Veteran’s private physician, V. B., M.D., indicated that the Veteran had been a patient of his since 2011.  He noted that it was his belief that the Veteran’s osteoarthritis and chondromalacia of the patella were service-related.  
The newly received evidence relates to previously unestablished elements of the claim of a current disability and a possible link between the current disability and service, and provides a reasonable possibility of substantiating the claim.  38 C.F.R. § 3.156(a).
For these reasons, the Board finds that the evidence received since the December 2009 rating determination is new and material to reopen service connection for a right knee disorder.  38 U.S.C. § 5108; 38 C.F.R. § 3.156.  The reopened issue will be addressed in the remand section below.
REASONS FOR REMAND
COPD
As it relates to the claim of service connection for COPD, the Board notes that the Veteran was afforded a VA examination in June 2013, at which time the examiner indicated that there was no evidence showing the Veteran had this condition during active military service.  The examiner also indicated that there was no objective evidence showing that the condition currently existed.  The examiner opined that the Veteran currently did not have a confirmed clinical diagnosis of COPD.
Subsequent to the examination, the Veteran submitted an April 2016 letter from his private treating physician, Dr. B., indicating that the Veteran had COPD which was military-service related.  Given the added medical evidence, the Veteran should be afforded an additional VA examination to determine the etiology of any current lung/respiratory disorder, to include COPD, and its relationship, if any, to his period of service.  
Blood Disorder, to Include Essential Thrombocythemia and Myelodysplastic Syndrome
As noted above, this matter was remanded for actions consistent with the March 2017 JMPR.  In the JMPR, the parties noted that the July 2015 VA examination report showed that the examiner reviewed the Veteran’s service records, and noted that a retirement examination from May 1994 was silent for thrombocytosis, and also noted a September 1994 VA lab report that showed a normal platelet count.  However, the examiner did not discuss service treatment records which appeared to show “high” levels of platelets.  Specifically, two in-service blood test slips: one that appeared to be dated in February 1992 (the date was unclear) showing a platelet count of 429, with “normal” on the slip being the range from 130-400, and another that appeared to be dated in May 1994 (again, the date was unclear) showing a platelet count of 479 (again, with normal being from 130-400).  The parties observed that the May 1994 blood test slip included the notation “Ret. Phys.” at the bottom.  The parties stated that given this evidence in the file, it did not appear that the examiner who conducted the July 2015 VA examination considered the Veteran’s correct history relating to his blood disorder, and the examination was therefore inadequate.  The parties stated that vacatur and remand of the issue was necessary to provide the Veteran with an adequate examination.  
Given the foregoing, the Veteran should be afforded an additional VA examination to comply with the directives of the JMPR.  
Diabetes Mellitus
As it relates to the claim of service connection for DM, the Board notes that the Veteran, in support of his claim, submitted a March 2010 statement from his private physician, Dr. S., who stated that it was at least as likely as not that the Veteran’s DM was related to his period of service, resulting from working conditions that the Veteran was exposed to in service.  
In connection with his claim, the Veteran was afforded a VA examination in January 2011.  Following examination, the examiner indicated that DMII was diagnosed after service, therefore less likely than not caused by or related to hyperglycemia reported in 1993.  She noted that service records were silent of DM diagnosis during service.  It was noted that the Veteran had a claimed disability pattern related to diabetes that met TL1001 criteria for a diagnosable chronic multisymptom illness with a partially explained etiology.  She stated it was less likely less likely than not caused by or related to GW environmental exposure and more likely than not related to ethnicity & weight (overweight).  
Subsequent to the January 2011 VA examination, the Veteran submitted a statement from his treating physician, V. B., M.D., who also indicated that it was his belief that the Veteran’s diabetes mellitus was military-service related. 
While the January 2011 VA provided a negative opinion, she did not address the March 2010 opinion from Dr. S.  Moreover, the opinion from Dr. B. was received subsequent to the January 2011 VA medical opinion.  Given the foregoing, the Veteran should be afforded an additional VA examination, with the examiner rendering an opinion as to whether the Veteran’s current DM is related to his period of service and to also address the opinions in favor of the Veteran’s claim of service connection for DM issued by Dr. S. and Dr. B.  
Dementia
A review of the record reveals that the Veteran has not been afforded a VA examination to determine the nature and etiology of any current dementia.  
The Veteran maintains that he currently has dementia as a result of a inservice fall where he hit his head in service or in the alternative that his service-connected headaches cause or aggravate dementia.  The Board notes that service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury.  38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, at 448 (1995) (holding that service connection on a secondary basis requires evidence sufficient to show that the current disability was caused or aggravated by a service-connected disability).  To establish secondary service connection, the law states that there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between a service-connected disability and the current disability.  See Wallin v. West, 11 Vet. App. 509, 512 (1998).  The Veteran should be afforded a VA examination to determine the etiology of any current dementia, if found, and its relationship, if any, to his period of service and/or his service-connected headaches.  
Left and Right Knee Disorders 
As noted above, the claims of service connection have been reopened warranting a de novo review of the issues.  As it relates to the claim of service connection for DM, the Board notes that the Veteran, in support of his claim, submitted a March 2010 statement from his private physician, Dr. S., who stated that the Veteran’s knee problems were caused by or a direct result of his service, to include injuries or working conditions while in service.  
In connection with his claim, the Veteran was afforded a VA examination in September 2010.  Following examination, the examiner indicated that the Veteran had a claimed disability pattern related to knee pain that met TL1001 criteria for a disease with a clear and specific etiology and diagnosis (degenerative joint disease) less likely than not caused by or related to GW environmental exposure, more likely than not age related.  
Subsequent to the September 2010 VA examination, the Veteran submitted a statement from his treating physician, V. B., M.D., who indicated that it was his belief that the Veteran’s osteoarthritis and chondromalacia of the patella were military service-related.  
While the September 2010 VA examiner provided a negative opinion, she did not address the March 2010 opinion from Dr. S.  Moreover, the opinion from Dr. B. was received subsequent to the September 2010 VA medical opinion.  Given the foregoing, the Veteran should be afforded an additional VA examination with the examiner rendering an opinion as to whether the Veteran’s right and left knee disorders are related to his period of service, and to also address the opinions in favor of the Veteran’s claim of service connection for left and right knee disorders issued by Dr. S and Dr. B.  
 

Entitlement to an increased evaluation for cervical spine degenerative disc disease is remanded.
As it relates to the claim for an increased evaluation for degenerative joint disease of the cervical spine, the last VA examination was performed in 2010.  Furthermore, the Court has recently held that 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities.  Correia v. McDonald, 21 Vet. App. 158 (2016).  Specifically, the Court concluded that the final sentence of 38 C.F.R. § 4.59 required testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.  Id.  A review of the evidence of record reveals that the prior examination regarding the Veteran's service-connected cervical spine failed to fully comply with the Court's holding in Correia.  As such, remand is required to obtain an adequate examination regarding the Veteran's service-connected cervical spine disorder.  See Id.; see also Barr, 21 Vet. App. 303.
The matters are REMANDED for the following action:
1. Undertake appropriate development to obtain all outstanding VA and/or private treatment records related to the Veteran's outstanding claims.  If any requested records are not available, the record should be annotated to reflect such and the Veteran notified. 
2. Schedule the Veteran for a VA examination to determine the nature and etiology of any current right and left knee disorders.  All indicated tests and studies are to be performed and all findings are to be reported in detail.  The entire record should be made available to the examiner and the examiner should note such review in his/her report.
The examiner should identify all left and right knee disorders.  The examiner is requested to render an opinion as to whether it is at least as likely or not (50 percent probability or greater) that any current right and left knee disorder is related to the Veteran’s period of service.
Complete detailed rationale is requested for any opinion that is rendered.  When rendering the opinion the examiner is requested to address and discuss the March 2010 and April 2016 opinions from the Veteran’s private physicians relating his knee conditions to service.  
3. Schedule the Veteran for a VA examination to determine the nature and etiology of any diabetes mellitus.  All indicated tests and studies are to be performed and all findings are to be reported in detail.  The entire record should be made available to the examiner and the examiner should note such review in his/her report.
The examiner is requested to render an opinion as to whether it is at least as likely or not (50 percent probability or greater) that any current diabetes is related to the Veteran’s period of service, to include exposure to environmental hazards during the Gulf War.  
Complete detailed rationale is requested for any opinion that is rendered.  When rendering the opinion, the examiner is requested to address and discuss the March 2010 and April 2016 opinions from the Veteran’s private physicians relating his diabetes mellitus to service. 
4. Schedule the Veteran for a VA examination, preferably by a pulmonary specialist, to determine the nature and etiology of any current lung/respiratory disorder.  All indicated tests and studies should be performed and all findings should be reported in detail.  The entire record should be made available to the examiner and the examiner should note such review in his/her report. 
The examiner is requested to identify all current lung/respiratory disorders, to include COPD.  After identifying these respiratory/lung disorders, the examiner requested to render an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any identified respiratory disorder that is found is related to the Veteran's period of service, to include as a result of exposure to any environmental hazards in service, including oil fires and smoke from burn pits.  When rendering these opinions, the examiner should comment on the numerous diagnoses of COPD in the record and the April 2016 statement from Dr. B. indicating that the Veteran has COPD related to his military service.  
Complete detailed rationale is requested for any opinion that is rendered.  
5. The Veteran should be scheduled to determine the nature and etiology of any current dementia.  All indicated tests and studies should be performed and all findings must be reported in detail.  The entire record must be made available for review and the examiner should note such review in his/her report.  After a complete review of the claims folder, the examiner is requested to offer the following opinions:
Is it as likely as not (50 percent probability or greater) that any current dementia, if found, is related to the Veteran’s period of service, to include exposure to environmental hazards while in service? 
If not, is it at least as likely as not (50 percent probability or greater) that the Veteran’s dementia, if found, is caused by the service-connected headache disorder?
If not, is it at least as likely as not (50 percent probability or greater) that any current dementia, if found, is aggravated by the service-connected headache disorder?  If aggravation is found, to the extent that is possible, the examiner is requested to provide an opinion as to approximate baseline level of severity of the nonservice-connected disorder before the onset of aggravation.
Complete detailed rationale is requested for any opinion that is rendered.
6. After all outstanding records have been associated with the record, schedule the Veteran for an appropriate VA examination to determine the etiology of any current blood disorder, to include essential thrombocythemia and myelodysplastic syndrome.  The claims file, including a complete copy of this remand, must be made available for review of the Veteran's pertinent medical history.  Any evaluations, studies, and tests deemed necessary by the examiner should be conducted. 
The examiner should opine as to whether it is at least as likely as not (a 50 percent or greater probability) that any current blood disorder, to include essential thrombocythemia and myelodysplastic syndrome is related to his military service, to include his reports of a platelet disorder and/or exposure to smoke and oil while serving in the Persian Gulf.  
The examiner should consider all evidence of record, including lay statements and medical records, to specifically include two in-service blood test slips: one that appeared to be dated in February 1992 (the date was unclear) showing a platelet count of 429, with “normal” on the slip being the range from 130-400, and another that appeared to be dated in May 1994 (again, the date was unclear) showing a platelet count of 479 (again, with normal being from 130-400), with the May 1994 blood test slip including the notation “Ret. Phys.” at the bottom.  Any opinions offered should be accompanied by clear rationale consistent with the evidence of record.
7. The Veteran should be scheduled for an appropriate VA examination to determine the current level of severity of his service-connected cervical spine disability.  The entire record must be made available to and reviewed by the examiner in conjunction with the examination.  The examiner should note in the examination report that the entire record has been reviewed.  All necessary tests should be conducted.
The examiner should describe the nature and severity of all manifestations of the Veteran's cervical spine disability.  In this regard, the examiner should record the range of motion observed on clinical evaluation in terms of degrees.  If there is clinical evidence of pain on motion, the examiner should indicate the degree at which such pain begins.  Then, after reviewing the Veteran's complaints and medical history, the examiner should render an opinion, based upon his or her best medical judgment, as to the extent to which the Veteran experiences functional impairments such as weakness, excess fatigability, incoordination, or pain due to repeated use or flare-ups, and should portray these factors in terms of degrees of additional loss in range of motion (beyond that which is demonstrated clinically), if feasible.
In order to comply with the Court's precedential decision in Correia, the examiner must test and record range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing, if applicable.  If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so.
If range of motion is not possible, the examiner should indicate whether the Veteran has favorable or unfavorable ankyloses of the cervical spine or unfavorable ankylosis of the entire spine.
If the examiner finds that the Veteran's service-connected cervical spine disability is manifested by any neurological impairment, he/she should indicate which nerves are involved, and the extent of the impairment (mild, moderate, moderately severe, or severe incomplete, or complete, paralysis of the affected nerve).  The examiner should also state whether the Veteran has intervertebral disc syndrome (IVDS).  If so, state whether IVDS results in incapacitating episodes, and if so, the duration of the episodes over the past 12 months. 
The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions.
8. Review the claims file.  If any development is incomplete, including if the examination report does not contain sufficient information to respond to the questions posed, take corrective action before readjudication.  See Stegall v. West, 11 Vet. App. 268 (1998).

 
K. PARAKKAL
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	T. S. Kelly, Counsel 

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